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,.n <br />l l._.( l Pub:m Works Permit • <br />Date—L LL_' <br />' BIEB. Dept. s _ <br />Application For <br />lic Works <br />Total FeeFeo S <br />PUBLIC WORKS PERMIT Pub <br />Less Appt Fee Paid S <br />Balance Due 9 <br />Print or Type Only <br />Owns ailing Address City Zip Phone <br />2 <br />aApplicat Mailing Address Zip <br />//C/�ity (Phone <br />Al 101 1 "-hh") I'd <br />Describe Proposed Work L�-�11.L1C— - <br />u <br />W <br />=� <br />H <br />Project Address (it known( <br />Attach four (4) copies of plans for proposed work - Draw to scale and note the following as applicable: <br />• Property Lines • Centerline of street <br />• Outline and dimensions of all existing and • Indicate North <br />proposed structures on the lot Y Show any proposed grading changes <br />• Existing and proposed utilities • Show measurements <br />M <br />DO NOT WRITE BELrTW THIS LINE <br />O <br />PERMIT CONDITIONS <br />1. All for inspection shall be made 24 hrs. in advance - phone 259.881 5. <br />calls <br />2. All work shall be performed in accordance with this permit and Current City of Everett Design and Construction <br />Standards and Specifications. <br />3. Call Location Underground Service 48 hrs. before you dig. TOLL FREE NUMBER 1.800.424.5555. <br />Tf�P�/tiff S�HGES lV61S7-.BF 4P /gel; <br />ffjJj�iPOd60 pGOT t'l"gw . '1;TTe o 7 0"-B7 <br />8EF0/zE b0vL-''r now er OCevf'iEO, <br />i <br />Approved for Co / Date <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />Ever tt, V,A Street <br />Everett, V.A 98201 <br />Phone: 259.8815 <br />GLC ASRYAGTED Cl) <br />0 <br />a <br />ACKNOWLEDGEMENT OF CONDITIONS <br />The undersigned owner/appl:;ant hereby agrees to hold and save harm- <br />less the City of Everett from any and all claims for damages, costs, <br />expenses, or causes of action that may arise because of installation <br />and maintenance of the improvement or other right-ol-way use hereto <br />applied for and further agrees to remove sam upon notice from the <br />City and to replace public property damage Areby. <br />Signature of Apfficant 1 Date <br />WORK AUTHORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAYS OF DATE PERMIT IS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY THE CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJECT OVER 90 DAYS DURATION. <br />